Multilevel Influence on the Opioid Crisis

The opioid crisis is climbing the ladder quickly to becoming one of the leading causes of death in Canada. More than 1,000 Canadians lost their lives to opioid overdoses in the first three months of 2018, a statistic that rose 16% from the same period in 2017. The Special Advisory Committee on the Epidemic of Opioid Overdoses reports new data that suggests a changing pattern of overdoses:

“We want to emphasize that the current crisis does not discriminate. It impacts people from all walks of life, all age groups and all socioeconomic backgrounds.”

Overdose-related deaths span across a wide spectrum of individuals – from those who have a history of chronic drug use to those who overdose on their first exposure. The increasing pressure placed on the Canadian health care system by the effects of the opioid crisis is significant. The Canadian Institute for Health Information (CIHI) reports that hospitalization as a result of apparent overdoses is at an alarming rate of 16 people per day.

Understanding the social determinants of health that contribute to inappropriate opioid drug use can inform promotion, prevention, and treatment strategies to combat the opioid crisis. The Social Ecological Model (SEM) considers that individual behaviour is influenced not only by our intrinsic traits and experiences, but also by interpersonal relationships, the community and institutions to which we belong, and by public policies in our society. The five levels of the SEM are as follows:

1. Intrapersonal - individual determinants (e.g. age, income, education, comorbidities)

2. Interpersonal - family, peers, and relationships that contribute to experiences influencing behaviour

3. Community - settings that contribute to the formation of social relationships above

4. Organizational / Institutional - policies in local institutions (e.g. hospitals) that may impact treatment strategies

5. Public Policies - societal factors that contribute to health, economic, educational, social policies that may contribute to factors predisposing inequity between populations

The relationship between these influencing levels is complex as impact can be multi-directional and across multiple layers.

I will delve further into the literature supporting each of these levels in a more in-depth blog post. Drawing from professional experience and a brief review of some evidence yielded the following initial thoughts:

Intrapersonal

• Comorbidities: mental disorders, acute or chronic pain

• Age

• Education background

• Income status

• Homelessness

• Heightened physiological reactions (i.e. having a greater subjective euphoric reaction)

• History of substance abuse

Interpersonal

• peer pressure

• family member with substance abuse or previous overdose

• adverse childhood experiences

Community

• geographic location – communities with high incidence of opioid abuse

• residential instability or mobility, homelessness

• availability of social support patients with substance abuse disorder

• availability of naloxone kits

Institutional

• physician opioid prescribing patterns

• frequency of follow up for patients on opioids

• institutional policies on destruction of opioids

• transitional care follow up

Public Policies

• advertising restrictions for pharmaceutical companies

• access to primary care to monitor prescription drug use

• stigma on substance abuse

• policies addressing illicit drug production, supply and distribution

• opioid use surveillance system

• integrated national/provincial health information system

• affordable housing

The opioid crisis is showing no signs of slowdown and continues to affect people in communities cross Canada. With the increasing media coverage of issues related to its impact on the Canadian population and our health care system, situational awareness has prompted federal, provincial, and institutional initiatives to address this national health crisis. A comprehensive solution must consider all levels of influence that contribute to opioid dependence and overdose.

References

Belzak, L., Halverson, J. (2018). Evidence synthesis – The opioid crisis in Canada: a national perspective. Health Promotion and Chronic Disease Prevention in Canada, 38(6): 221-233. DOI: https://doi.org/10.24095/hpcdp.38.6.02

Canadian Institute for Health Information. (2018). Opioid crisis having “significant impact on Canada’s health care system. Retrieved from https://www.cihi.ca/en/opioid-crisis-having-significant-impact-on-canadas-health-care-system

Centers for Disease Control and Prevention. (2018, February 20). The Social-Ecological Model: A Framework for Prevention. Retrieved from https://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

Young, L. (2018, June 20). Nearly 4,000 Canadians died of opioid overdoses in 2017, a new record. Global News. Retrieved from https://globalnews.ca/news/4282699/canada-opioid-death-statistics-2017/

Young, L. (2018, September 18). Opioid overdoses killed more than 1,000 Canadians in the first quarter of 2018. Global News. Retrieved from https://globalnews.ca/news/4462191/opioid-overdoses-2018-stats/